Is The Rehab Field Doomed To Failure?

[Myofascist]

I guess I meant questioning if PM+R is a worthwhile field. We should all question what we do for a patient before we do it.

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[pmr2010]

2 things to consider are this:

Physiatrists are very well trained in emg during their residency training.

In a meta-analysis of 1437 patients with stroke, decreased death and improved functional outcome was shown in rehab units vs gen med ward. that's evidence.

 

[PMR 4 MSK]

On the original question - I believe that inpatient rehab is doomed. Not so much by a lack of quality work, but by modern economics. We have failed as an organization to prove that what we do not only works, but is financially responsible, as in does spending several thousand dollars a week for several weeks on a stroke patient truely result in improved functional outcomes that justify that expenditure. Insurance companies have picked up on this, even Medicare questions it. Quality research in this area is severly lacking.

As a resident, I questioned this extensively; as a former inpatient Medical Director I confirmed it - for most patients, we are getting paid to babysit them (and really not paid very well). We write similar notes day after day. We handle medical problems until they need another specialist. The one thing I think we do the best on the inpatient ward is preventionology. All else could be handled by an FP/IM. The fact is they don't want to do it. That's a void filled by PM&R by those who want to.

As for the outpatient arena, we should be poised as a field to elevate ourselves to a prime position in medicine. We are the musculoskeletal experts! The #2 complaint to go see a PCP is back pain and/or other musculoskeletal pains. The PCP's worst area of training? - the very same.

Nobody does spine like we do. No one else does spine, neuro, rheum, ortho, and sports med, together with EMGs and pain like a well-trained PM&R doc. The orthopods are learning it - most larger ortho clinics have or want PM&R docs - it's a win-win.

The problem right now is we're paying for the sins and transgressions of our forefathers (with all due respect to Krusen et. al.). They let our field become the butt of jokes, and failed to make our field shine. They led us to the point where half our residency positions are left to FMGs, ranking us near the bottom on that scale.

How do we save our field? We talk to everyone - other docs, medical professions, patients, family and friends. We need to tell people what we do and be proud of it!

I don't save lives. I did not go into ER or surgery. I restore function and relieve pain. When people ask me what PM&R is, that's my short answer. I do it with meds, PT/OT, injections and advice. I give talks - at hospital grand rounds, to medical students, to therapists, to the public. I do it all gratis (I refuse to speak for drug companies anymore - it's not worth it in the long run...). At every talk I try and answer that one question - what does a physiatrist do?

Easy answer - I restore function and I relieve pain.

 

[Disciple]

On the original question - I believe that inpatient rehab is doomed. Not so much by a lack of quality work, but by modern economics. We have failed as an organization to prove that what we do not only works, but is financially responsible, as in does spending several thousand dollars a week for several weeks on a stroke patient truely result in improved functional outcomes that justify that expenditure. Insurance companies have picked up on this, even Medicare questions it. Quality research in this area is severly lacking.

As a resident, I questioned this extensively; as a former inpatient Medical Director I confirmed it - for most patients, we are getting paid to babysit them (and really not paid very well). We write similar notes day after day. We handle medical problems until they need another specialist. The one thing I think we do the best on the inpatient ward is preventionology. All else could be handled by an FP/IM. The fact is they don't want to do it. That's a void filled by PM&R by those who want to.

As for the outpatient arena, we should be poised as a field to elevate ourselves to a prime position in medicine. We are the musculoskeletal experts! The #2 complaint to go see a PCP is back pain and/or other musculoskeletal pains. The PCP's worst area of training? - the very same.

Nobody does spine like we do. No one else does spine, neuro, rheum, ortho, and sports med, together with EMGs and pain like a well-trained PM&R doc. The orthopods are learning it - most larger ortho clinics have or want PM&R docs - it's a win-win.

The problem right now is we're paying for the sins and transgressions of our forefathers (with all due respect to Krusen et. al.). They let our field become the butt of jokes, and failed to make our field shine. They led us to the point where half our residency positions are left to FMGs, ranking us near the bottom on that scale.
.[/COLOR].[/COLOR]

Two things:

1. Inpatient Physiatrists (medical directors) admit inappropriate patient just like some outpt Physiatrists perform inappropriate injections. If that is going to go on in the inpt setting, at the very least do the right thing for the specialty and use midlevels instead sacrificing the training of residents and the future of the specialty.

2. Nobody does spine like some Physiatrists do. We like to make that claim, but to have anybody believe it (especially doctors who perform similar services as well as insurance companies) we've got to raise our standards to all or at the very least most.

 

[Bleurberry]

This thread should be elevated to sticky note status.
I just wanted to say I had the good fortune of attending the
AAPM&R Assembly's medical student workshop in Boston last weekend.
axm297 was representing the field in the best way through her presentation to us students, and all of the speakers were really great; the trip from Philly and back was worthwhile. I was only sad that I hadn't the time to wander the whole conference.
The medical student workshop is a great idea and I hope they expand the program to other venues than just the national assembly. I'm a pre-med at Temple, I'm making sure not only my pre-med friends and associates know full well the existence of PM&R, but so too our pre-med adviser and anyone else I meet along the way. The best things travel through word of mouth. In the meantime, thanks for your opinions, thoughts, etc. of your work.

 

[savealife]

How many medical students were present? I was sad I couldn't make it. But I'd still be interested in seeing how many MSs made their way to Boston, and also where they were in their training (MSI, MSII, MSIII, MSIV)...

 

[PMR 4 MSK]

Two things:

1. Inpatient Physiatrists (medical directors) admit inappropriate patient just like some outpt Physiatrists perform inappropriate injections. If that is going to go on in the inpt setting, at the very least do the right thing for the specialty and use midlevels instead sacrificing the training of residents and the future of the specialty.

2. Nobody does spine like some Physiatrists do. We like to make that claim, but to have anybody believe it (especially doctors who perform similar services as well as insurance companies) we've got to raise our standards to all or at the very least most.

I approached my hospital CEO about a midlevel to do much of the work on the inpt ward- he nixed it quickly. I still think that's a very appropriate role for NPs and PAs. I did hire one for my office, but it didn't work out financially - since she wasn't formally pain trained she needed too much direct supervision.

Amen to #2!

 

[drrinoo]

The problem right now is we're paying for the sins and transgressions of our forefathers (with all due respect to Krusen et. al.). They let our field become the butt of jokes, and failed to make our field shine. They led us to the point where half our residency positions are left to FMGs, ranking us near the bottom on that scale.

How do we save our field? We talk to everyone - other docs, medical professions, patients, family and friends. We need to tell people what we do and be proud of it!


Your comment about FMGs is disconcerting. FMGs, ie., IMGs (including the carribean medical students) in PM+R have contributed immensely to the field. Although they do not have a sizable visibility in the AAPMR, they represent an immense resource for the field of physiatry.

FMGs are not responsible for PMR being the 'butt of jokes', as you have alluded. In fact, most of the physiatrists that I know that do cutting edge interventional pain are FMGs.

Physiatry is a great field because of physiatrists themselves--not because of PMR materia medica. We collectively represent a field of innovators that have historically thought outside of the box. Don't be so narrow minded.

 

[PMR 4 MSK]

The problem right now is we're paying for the sins and transgressions of our forefathers (with all due respect to Krusen et. al.). They let our field become the butt of jokes, and failed to make our field shine. They led us to the point where half our residency positions are left to FMGs, ranking us near the bottom on that scale.

How do we save our field? We talk to everyone - other docs, medical professions, patients, family and friends. We need to tell people what we do and be proud of it!


Your comment about FMGs is disconcerting. FMGs, ie., IMGs (including the carribean medical students) in PM+R have contributed immensely to the field. Although they do not have a sizable visibility in the AAPMR, they represent an immense resource for the field of physiatry.

FMGs are not responsible for PMR being the 'butt of jokes', as you have alluded. In fact, most of the physiatrists that I know that do cutting edge interventional pain are FMGs.

Physiatry is a great field because of physiatrists themselves--not because of PMR materia medica. We collectively represent a field of innovators that have historically thought outside of the box. Don't be so narrow minded.

I don't disagree with the contribution of FMGs, but the sad fact is that % of FMGs in a field is considered (probably erroneously) a measure of the talent strength of the field, and is a special point of pride to residency programs. Most residency programs seem to rate candidates:

1) US born and trained MD
2) US born and trained DO
3) FMG's

Maybe I'm wrong, but that seems to be the general strategy for ranking candidates by programs. Americans are prejudiced in this regard.

If PM&R were considered a more of a desirable field with a better future, it would attract more American trainees. In my residency we had a former pediatric surgeon, an orthopedic surgeon and 2 internists who all admitted they could not get into their chosen fields in America. They are all very fine PM&R docs and I would be proud to work with any of them. It is sad though that PM&R becomes their back-up plan and/or only way of practicing medicine in America.

As I was graduating my program, the entire entering class after me was 100% FMGs. Our attendings considered that a complete failure of recruiting and started having meetings on how to reverse that. One of them had just finished his GI fellowship after IM residency. He had no real interest in PM&R, he just wanted to stay in America. I don't blame him.

My class was 3/4 American trained, the one after me 1/2, then 1/4, then 0. It's like a college football team that can't recruit the best players because it does not currently have the best players. Again, the sad fact is, the % of FMGs in a residency program is seen as a measure of their desirability.

So I apologize for blaming FMGs - it's not your fault and I am glad to have you here. FMGs are rightfully taking advantage of what American trained physicians are passing on and/or don't know about. But I don't believe that either residency programs or the rest of the medical field in general sees that higher % of FMGs in our field as a strength, but rather a weakness of the field.

One of the recent publications from the ABPM&R discussed their concern that PM&R ranks so low on % of positions filled by American grads. Hopefully that will change with time - either the perception that that is bad, or more of today's medical students will become interested in PM&R.

 

[DigableCat]

Your comment about FMGs is disconcerting. FMGs, ie., IMGs (including the carribean medical students) in PM+R have contributed immensely to the field. Although they do not have a sizable visibility in the AAPMR, they represent an immense resource for the field of physiatry.

FMGs are not responsible for PMR being the 'butt of jokes', as you have alluded. In fact, most of the physiatrists that I know that do cutting edge interventional pain are FMGs.

Physiatry is a great field because of physiatrists themselves--not because of PMR materia medica. We collectively represent a field of innovators that have historically thought outside of the box. Don't be so narrow minded.

Whether we would like to accept it or not, medical school students judge the competitiveness of a field by how hard it is to get accepted into it. By having a field have a plethora of IMGs, it only goes to support the notion that

A) Anyone can match into it
B) AMGs don't find it particularly attractive
therefore
C) It must not be that great of a field.

Unfortunately, it becomes a neverending cycle. Medical school students avoid, IMG fills spot, Medical school students see IMGs fill the spots, Medical school students avoid.

It happens much the same as it does with certain malignant residency programs...although even malignant residency programs in competitive specialities will still fill. Go figure.

What needs to happen is better advertisement and introduction of our field during the 1st three yrs of medical school. This includes having residents help in cadaver labs, our attendings teaching during Anatomy and Neuroscience courses, as well as being involved in PBLs. It's a shame we have to sell the field, but if it has to be done...it has to be done.

I'd like to think that for most PM&R is a chosen field, and not a field they ended up in because they couldn't get their initial pick. Very few people "settle" for Orthopedics, Plastic Surgery, or Radiology.

 

[Triathlon]

I really like this last post because it is very revealing. We need to look at the source. The pool of potential candidates. They are ignorant of the field of PM&R. I am currently doing my internship before starting residency and I can't believe how many times I have had to explain to my colleagues exactly what a physiatrist is. This was even more common in medical school. Nobody knows what it is when they need to be exploring options. By the time many learn about the field it is too late, they have invested too much effort and concentration on other fields. I had never heard of it until late in my first year of medical school. I was hoping to do family/ sports med but couldn't handle the idea of doing FP. How relieved I was when I was enlightened. I was lucky to have run into the right person at the right time. I think another aspect is the difficulty we have describing the field. What exactly do we do? Restore function and relieve pain is a great descriptor when you know what that means. But to the rest it sounds like that is what all physicians do. We need a more descriptive catch phrase. Whenever I use the word musculoskeletal I get the most understanding and respect. Also "geriatric sports medicine" gets some laughs but understanding.

 

[topwise]

I'm confused... I thought PM&R was getting more competitive these days? I have zero FMGs in my program.

 

[WaterAvatar]

I'm applying for PMR positions this year and intend to be a salesman for the field to the misguided individuals of our country... stay tuned.

 

[drusso]

Although they do not have a sizable visibility in the AAPMR, they represent an immense resource for the field of physiatry.

Why do you think this is the case?

 

[axm397]

How many medical students were present? I was sad I couldn't make it. But I'd still be interested in seeing how many MSs made their way to Boston, and also where they were in their training (MSI, MSII, MSIII, MSIV)...

There were about 50 med students - about 60-70% MSIVs, some MSIIIs, and a few MSI and MSII and don't forget the pre-med student!!

I have been meeting more and more US MD grads who didn't match in PM&R. I think part of it is that the more undesirable programs (don't ask me where they are) aren't even on the radar of the US MD grads - so they go unmatched rather than scramble into one of those. Frankly, my opinion would be to close down the worst few programs - especially those without quality education and faculty members - to prevent those with substandard training to go on and represent our field.

In terms of IMGs and FMGs - some of the brightest physicians I know are IMGs and FMGs and the best IMGs and FMGs will find spots in PM&R even if they shut down a few programs.

I know that having less graduates mean less visibility for our field but I'd rather have fewer high quality physiatrists graduating each year than the alternative.

Obviously, the mid to upper level residency programs are more competitive - and many on this board trained or are training at some of those programs - and they see people go unmatched and see high quality applicants each year.

I think the physiatric approach to patients is what makes us unique - whether it's in the inpatient or outpatient setting.

To roughly quote our CEO "We are experts in disabling conditions affecting muscles, bones, and nerves(including brain), who can best assist patients achieve their maximum functional potential because we understand the pathophysiology, typical course, and complications associated with those conditions. We have a whole arsenal of tools including medication, modalities, and interventions to offer our patients to help them get to their goals."

Even in the MSK outpatient setting - we ask, "what can't you do now because of your condition that you could do before?"

 

[drrinoo]

I don't disagree with the contribution of FMGs, but the sad fact is that % of FMGs in a field is considered (probably erroneously) a measure of the talent strength of the field, and is a special point of pride to residency programs. Most residency programs seem to rate candidates:

1) US born and trained MD
2) US born and trained DO
3) FMG's

Maybe I'm wrong, but that seems to be the general strategy for ranking candidates by programs. Americans are prejudiced in this regard.

If PM&R were considered a more of a desirable field with a better future, it would attract more American trainees. In my residency we had a former pediatric surgeon, an orthopedic surgeon and 2 internists who all admitted they could not get into their chosen fields in America. They are all very fine PM&R docs and I would be proud to work with any of them. It is sad though that PM&R becomes their back-up plan and/or only way of practicing medicine in America.

As I was graduating my program, the entire entering class after me was 100% FMGs. Our attendings considered that a complete failure of recruiting and started having meetings on how to reverse that. One of them had just finished his GI fellowship after IM residency. He had no real interest in PM&R, he just wanted to stay in America. I don't blame him.

My class was 3/4 American trained, the one after me 1/2, then 1/4, then 0. It's like a college football team that can't recruit the best players because it does not currently have the best players. Again, the sad fact is, the % of FMGs in a residency program is seen as a measure of their desirability.

So I apologize for blaming FMGs - it's not your fault and I am glad to have you here. FMGs are rightfully taking advantage of what American trained physicians are passing on and/or don't know about. But I don't believe that either residency programs or the rest of the medical field in general sees that higher % of FMGs in our field as a strength, but rather a weakness of the field.

One of the recent publications from the ABPM&R discussed their concern that PM&R ranks so low on % of positions filled by American grads. Hopefully that will change with time - either the perception that that is bad, or more of today's medical students will become interested in PM&R.

No need to apologize to me...I graduated from Hopkins Med.

The percentage of IMGs in a discipline reflects on the discipline itself, rather than the caliber of physicians entering the specialty. For instance, I would wager that a typical medical student would get turned off when faced with lecture about gait analysis or prescribing wheelchairs. Out of a group of 100 medical students, 1-2 may say..'Yes, this is exactly what I want to do for the rest of my life'. Similarly, as alluded in another post, a medical student can peruse through 1-2 years of the Archives of PMR vs. Annals of IM, Annals of Surgery, JBJS, Anesthesia and Analgesia...to get an understanding of current, clinically applicable research....there is no contest on which career path a medical student would choose based on a review of those journals.

On the other hand, physiatrists should come to terms with the diversity of medical degree origins in the field. If the field of physiatry cannot figure out what to do with a PhD in Molecular Biology held by an MD of Chinese origin, a former Korean neurosurgeon, a former Romanian surgeon, a former Indian orthopedic surgeon, a former Korean obstetrician, a former Chinese neurologist, then at least they should not disparage the careers of these individuals into a nuisance statistic (%IMGs in training)...mind you these IMGs have faced incredible financial and social hurdles to secure their training in the USA

It is a travesty to marginalize the achievements of IMGs; physiatry cannot afford this kind of arrogance, unlike some of the most competitive specialties.

Ideally, the strength of physiatry rests in the individual practicing physiatrists out in the community. The strength in the job market for physiatrists is a testament these individuals and not necessarily to the prestige of the academic programs. A number of IMGs have gone on to practice in smaller communities and have slowly built their reputations. This type of grass roots community impact ultimately helps the job market for future physiatry.

Obviously, the interventional physiatry fellowships and accessibility of ACGME sub specialty accreditation are major contributors to the job market of pm+r--but the efforts of individual practitioners in their communities also contribute.

 

[paindefender]

[I have been meeting more and more US MD grads who didn't match in PM&R. I think part of it is that the more undesirable programs (don't ask me where they are) aren't even on the radar of the US MD grads - so they go unmatched rather than scramble into one of those.

In few words, the specialty is so mediocre that it cannot provide decent training to the few US grads that apply.

 

[axm397]

I have been meeting more and more US MD grads who didn't match in PM&R. I think part of it is that the more undesirable programs (don't ask me where they are) aren't even on the radar of the US MD grads - so they go unmatched rather than scramble into one of those.

[In few words, the specialty is so mediocre that it cannot provide decent training to the few US grads that apply.

huh? I don't get paindefender's conclusion - my point was that the top tier programs are competitive just like in any specialty and that the lowest level programs go unfilled because they are subpar. US grads that i've seen go unmatched ranked too many top tier programs and didn't rank the mid to lower level programs and didn't like the options presented during the scramble.

How that translates to "the specialty is so mediocre..." - I have no idea. did you even read the rest of my post?

 

[ampaphb]

huh? I don't get paindefender's conclusion - my point was that the top tier programs are competitive just like in any specialty and that the lowest level programs go unfilled because they are subpar. US grads that i've seen go unmatched ranked too many top tier programs and didn't rank the mid to lower level programs and didn't like the options presented during the scramble.

How that translates to "the specialty is so mediocre..." - I have no idea. did you even read the rest of my post?

you are letting yourself get baited by a troll

 

[lobelsteve]

you are letting yourself get baited by a troll

Ditto.
Consider the ignore user function.
Turns trolls to stone.

 

[Llenroc]

I don't disagree with the contribution of FMGs, but the sad fact is that % of FMGs in a field is considered (probably erroneously) a measure of the talent strength of the field, and is a special point of pride to residency programs. Most residency programs seem to rate candidates:

1) US born and trained MD
2) US born and trained DO
3) FMG's

Maybe I'm wrong, but that seems to be the general strategy for ranking candidates by programs. Americans are prejudiced in this regard.

If PM&R were considered a more of a desirable field with a better future, it would attract more American trainees. In my residency we had a former pediatric surgeon, an orthopedic surgeon and 2 internists who all admitted they could not get into their chosen fields in America. They are all very fine PM&R docs and I would be proud to work with any of them. It is sad though that PM&R becomes their back-up plan and/or only way of practicing medicine in America.

As I was graduating my program, the entire entering class after me was 100% FMGs. Our attendings considered that a complete failure of recruiting and started having meetings on how to reverse that. One of them had just finished his GI fellowship after IM residency. He had no real interest in PM&R, he just wanted to stay in America. I don't blame him.

My class was 3/4 American trained, the one after me 1/2, then 1/4, then 0. It's like a college football team that can't recruit the best players because it does not currently have the best players. Again, the sad fact is, the % of FMGs in a residency program is seen as a measure of their desirability.

So I apologize for blaming FMGs - it's not your fault and I am glad to have you here. FMGs are rightfully taking advantage of what American trained physicians are passing on and/or don't know about. But I don't believe that either residency programs or the rest of the medical field in general sees that higher % of FMGs in our field as a strength, but rather a weakness of the field.

One of the recent publications from the ABPM&R discussed their concern that PM&R ranks so low on % of positions filled by American grads. Hopefully that will change with time - either the perception that that is bad, or more of today's medical students will become interested in PM&R.

Be careful where you tread. On another thread, I implied that American residency programs favor *gasp* American MD candidates over DO's and FMG's, and soon enough I was being compared to Adolf Hitler.

 

[Dr. Ice]

Be careful where you tread. On another thread, I implied that American residency programs favor *gasp* American MD candidates over DO's and FMG's, and soon enough I was being compared to Adolf Hitler.

perhaps the field should take on the attitude of internal medicine residency programs and accept the most qualified applicants into their programs. Most IM residency programs have a significant pool of IMGs. Does that weaken the programs? very doubtful. Perhaps I am speaking too ideally, but thats the way it should be.

 

[Disciple]

One of the recent publications from the ABPM&R discussed their concern that PM&R ranks so low on % of positions filled by American grads. Hopefully that will change with time - either the perception that that is bad, or more of today's medical students will become interested in PM&R.

I think you're referring to a commentary by Dr. Braddom in the spring issue of The Physiatrist in which he takes note of the fact that PM&R has the lowest percentage of medical students matched who have AOA membership. In the commentary, he also takes note that over 45% of students who match into Derm have AOA membership and then goes on to state that by 2017 we should make it our goal that 50% of students matching into PM&R have AOA membership.

Realistically speaking, I don't see what the use is. Most with common sense are aware of the two main reasons, other than genuine interest in the field, why students go into Derm, Rad Onc and the ROADS specialties. Add in prestige and that also covers Plastics, Neurosurg, Ortho and ENT.

Unless we're ready to come to terms with/accept and embrace these 3 unavoidable facts, there is no point in coming up with goals that will be impossible to achieve.

 

[lucyz02]

I agree with disciple, possibly another angle to look at it is that by have less AOA member we are actually more well rounded - the exact type of candidate allot of programs look for. Someone with outside interests other that gearing their success to be that top percent in the class is someone that is more interesting and has more to offer as a candidate. AOA status alone isn't a great measure of PM&R success as a specialty. Just a thought.... please don't take anything above personally if you have AOA status.

 

[drusso]

I think you're referring to a commentary by Dr. Braddom in the spring issue of The Physiatrist in which he takes note of the fact that PM&R has the lowest percentage of medical students matched who have AOA membership. In the commentary, he also takes note that over 45% of students who match into Derm have AOA membership and then goes on to state that by 2017 we should make it our goal that 50% of students matching into PM&R have AOA membership.

Realistically speaking, I see what the use is. Most with common sense are aware of the two main reasons, other than genuine interest in the field, why students go into Derm, Rad Onc and the ROADS specialties. Add in prestige and that also covers Plastics, Neurosurg, Ortho and ENT.

Unless we're ready to come to terms with/accept and embrace these 3 unavoidable facts, there is no point in coming up with goals that will be impossible to achieve.

Great post. I've always wondered what people find intellectually stimulating about derm. I did a derm rotation in medical school and thought it was "okay," but an awful lot like primary care in terms of work pace and patient care.

I think that physiatry is actually pretty intellectually stimulating if you're into complex patient care issues. But, the specialty doesn't do a good job "selling" itself.

 

[dutchman]

Just thought I might throw in my .02 cents on non-intuitive reasons why a person might show up on this thread and bash an entire specialty.

-They might actually like the specialty so much that they want it all to themselves.

-They recently lost a spouse/girlfriend/boyfriend to a PM&Rist.

-They are not in the specialty but wish they were.

-Good old fashioned *******.

Op, this is what happens when you make an uninformed decision. Sorry to reduce you to the level of pre-med, but maybe you need to go shadow some physiatrists.

 

[TRAMD]

These types of doomsday predictions preceeded the meteoric rises of radiology and anesthesiology. PM&R will be fine, better than fine. Has a specialty ever really died? The field is evolving but I don't see unemployment in the vast majority of physiatrists' future.